OCCUPATIONAL THERAPY PEDIATRIC INITIAL EVALUATION
Client Profile
Name:
Age/Sex:
Date of Birth
Diagnosis:
Referral Source:
Informant/s:
Contact Number:
Therapist-in-charge:
Date of Initial Evaluation:
BACKGROUND INFORMATION
I. Chief complaint
II. OT Goals
III. History of Present Illness (maternal, prenatal, perinatal, post-natal history)
*relevant details ONLY
Maternal History
Prenatal History
A. Personal History
a. Illnesses Suffered as a child
b. Previous medical conditions
c. Chronic illnesses
d. Hospital stays
B. Surgery History
a. Minor surgical operations
b. Major surgical operations
c. Anesthesia
d. Accidents requiring hospitalization
C. Medication history
a. Current prescription medications
b. Current OTC medications
c. Previous prescription medications
d. Medication based creams and lotions (prescription/non-prescription)
D. Lifestyle history
a. Smoking
b. Drinking
c. Eating habits
d. Weight loss
e. Weight gain
E. Previous pregnancy history
a. Previous full term pregnancies
b. Previous aborted pregnancies
c. Miscarriages
d. Multiple pregnancies
F. Gynecology history
a. Cycle (normal/abnormal)
b. Blood flow (normal/abnormal)
c. Endometriosis
d. Pelvic Inflammatory disease
e. Other gynecological problems
G. Infectious diseases
a. History of all infectious diseases (cures and ongoing)
H. Current pregnancy history
a. Date of last period
b. Date of positive pregnancy test
c. Cramping
d. Bleeding
e. Vaginal discharge
I. Complete parental and father medical history
a. Pregnancy complications
b. Chronic illnesses
c. Multiple births
d. Ethnic background
Notes:
Pt was born (Full / Pre / Post ) term via ( NSD / CS ) to a GP() ____ y/o mother
Indicate if mother had vices during the pregnancy; illnesses or problems encountered
If pre-natal check ups were conducted
If possible indicate activities of the mother during the pregnancy
Perinatal History
Child’s gestational age (i.e. degree of maturity) at birth
Presentation of child and delivery type
Complications in neonatal period
Indicate if mode of delivery, hospital; were there complications
APGAR score (if recalled); Birth weight
Newborn screening test/s and results (if any)
Postnatal History
When did the primary caregiver noticed signs or symptoms (indicate specific age)
Note the general behavior of the client including the age when specific skills were achieved (e.g. self-help
etc)
What prompted them to consult a doctor? When was consult made? What was the diagnosis?
Doctor’s orders
Did the child receive any services prior to evaluation? (OT, SLP, PT, SPED, or any form of intervention). If he
received OT services, what were the past managements given?
Doctor’s Orders
Other Therapeutic Intervention
IV. Performance Patterns
A. Roles
B. Routine
WEEKDAYS
Day Time Activity
Monday
Tuesday
Wednesday
Thursday
Friday
WEEKENDS
Day Time Activity
Saturday
Sunday
C. Habits
Useful Dominating Impoverished
V. Context and Environment
A. Physical
Describe the context (number of rooms; floors/ where does the child spend most of his time; where
does he sleep etc)
B. Personal- Social
Pt is ___among ____sibling/s.
Primary caregiver: __________________
Relationship with: Parents/Caregiver:
Educational Level of parents / caregivers:
Parent’s occupation / means of support:
Attitude of family towards disability / therapy
Play preferences/opportunities:
As observed by the caregiver
If possible, subjective information from the patient/child
Ano yung mga madalas niyang nilalaro sa bahay?
Naglalaro ba siya sa labas ng bahay?
Meron ba siyang mga kalaro?
Educational History:
Indicate if child is currently attending the school; contextualize (number of students, typical activities, subjects,
etc.)
C. Cultural
D. Virtual
E. Temporal
VI. Developmental history / Milestones: (provide only milestones relevant to the case ; indicate reference)
Example: (Molnar, 1999)
Skills Age Expected Age Achieved
Gross Motor Milestones
Sits independently 10 months
Stands independently 1 year old
Walks well 1 year old
Runs well 2 years old
Jumps in place 2 years old
EVALUATION
PERFORMANCE SKILLS
(Include only relevant skills to the case / diagnosis)
I. Work Behavior
Grading Remark/s
(G/F/P)
a. Compliance Type/demands of activity given:
Response:
b. Sitting span Type/demands of activity given:
Response:
c. Attention span Type/demands of activity given:
Response:
d. Concentration Type/demands of activity:
Response:
e. Impulse Control Type/demands of activity given:
Response:
f. Frustration Type/demands of activity given:
tolerance Response:
g. Ability in following Type/demands of activity given:
instructions Response:
II. Postural Control and Sensorimotor skills
a. Range of motion (ROM)
Grade Right Left
UE (reach objects above and ahead with both hands)
LE ((Indian sitting – hip ER, hip abd, knee flexion; standing – knee extension; walking – plantar,
dorsi, hip flexion)
Others
b. Muscle strength
MUSCLE STRENGTH: UE / LE / Trunk
For UE: Indicate the functional activity used to test and the response of the child/client (check if able
to grip and carry objects, able to carry heavy objects)
For LE:
For Trunk:
MUSCLE BULK: Note if there is atrophy or hypertrophy
c. Functional Grip Strength (indicate grading for R & L side)
d. Functional Pinch Strength (indicate grading for R & L side)
e. Muscle endurance
f. Postural Responses
Reaction Prone Sitting Standing
Righting ( sway in
vestibular ball)
Protective (tulak)
Front
Sideways
back
Equilibrium
g. Muscle tone
Normotonic Hypertonic Hypotonic/
Flaccid
(Modified Ashworth)
UE
LE
TRUNK
OTHER PERTINENT FINDINGS:
Indicate if client is using any ambulatory aids, assistive devices; augmentative communication
devices; deformities
h. Reflexes
( ) Integrated
( ) Primitive Reflexes
Moro
ATNR
STNR
Positive Supporting
Palmar Grasp
Plantar Grasp
III. Gross Motor Skills
GMS (if hindi kaya
while sitting or Remarks
Age-appropriate Age innapropriate
standing, ask to lie (duration, level of assist, activity)
down etc)
HEAD CONTROL
pull to sit
Prone
Sitting
TRUNK CONTROL
rolling over
prone on elbows
prone on hands
Sitting
PELVIC CONTROL
pelvic bridging
Quadruped
Kneeling
Standing
Advanced GMS (relevant)
For example:
Grading (AI/AA) Remark/s
Mature Jumping (3-5)
Run (3)
Hop (4)
Walk on Balance beam
Skipping
Throwing
Catching
Kicking
Transition / Mobility Patterns
Pattern Remarks Pattern Remarks
( ) prone to supine ( ) crawling (parang
quadruped)/ creeping
(belly)
( ) supine to prone ( ) kneeling to standing
( ) supine to sitting ( ) cruising
( ) sitting to kneeling ( ) walking
( ) prone to supine
Pre-writing/ writing skills
Skill Remarks
( ) Imitative Scribble
( ) Spontaneous Scribble
Tracing Line
Shap
e
Letter
Imitation Line
Shap
e
Letter
Copying Line
Shap
e
Letter
Pre-cutting/ Cutting Skills
Skill Remarks
Line (3)
Curve (5-7 zigzag
( ) Cut and curves)
Shapes (3.5 circle
triangle, 4.5
square)
( ) Cut Pictures/ Figures
( ) Mature Scissor Grasp
( ) Complex Cutting (5)
IV. Fine Motor Skills
a. Hand preference / dominance / handedness
b. RGCR (present, absent , emerging)
R L Remark/s
Reach
Grasp
Carry
Release
c. Prehension patterns (GPP, FPP) (indicate grading for R & L side)
Gross Prehension
R L Remark/s
Spherical
Cylindrical
Hook
Fine Prehension
R L Remark/s
Lateral
Tripod
Pad to pad
Tip to Tip
d. In-hand manipulation skills (indicate grading for R & L side)
R L Remark/s
F-P
Translation
P-F
Translation
Simple
Rotation
Complex
Rotation
Shifting
e. Fine motor coordination
Grading (+/-) Remark/s
Asymmetrical
Symmetrical
Reciprocal
Bilateral
Coordination
(fan)
Eye-Hand
(buttons)
Arm-Hand
Midline Crossing
(matching dapat
across midline)
V. Cognitive Skills
Grading Skill Remarks
Ability to follow ____step
directions
Imitation (2)
(motor/ verbal); in hockie pockie
action song
Memory
Common Objects (car, pencil,
lego)
Body Part (head and shoulders
action song)
Shape (shape sorter)
Size (circle tower)
Color (circle tower)
Number (clock)
Alphabet
Positional (numbers on clock)
Other Cognitive Skills:
Calculation (Rote counting 3-4;
1:1 correspondence 4-6)
VI. Executive Function
Emotional Regulation Skills
a. stranger anxiety
b. separation anxiety
c. others
Skill Grading Remark/s
(G/F/P)
Flexibility
Planning
Organization
Time Management
Working Memory
Goal-Directed Persistence
Metacognition
Task Initiation
Emotional Control
VII. Communication and Social Skills
a. functional comprehension and expression
b. other communication and social skills
Grading (+/-) Remark/s
Expressive Verbal
Non-verbal
Receptive Verbal
Non-verbal
Social Interaction Skills (relevant)
For example:
Skill AA/AI Remark/s
Approaches/Starts
Turns Toward
Regulates
Thanks
Takes Turns
Gesticulates
Looks
Questions
Replies
[Link]- Perceptual Skills
1. Sensory Functions and Pain
a. Sensory processing / integration (include red flags)
SSBs/SIBs:
As Reported Observed
b. Seeing and related functions
Grading (+/-) Remark/s
Oculomotor
Functions
Visual
Localization
Visual
Tracking
Saccades
c. Hearing functions
Grading (+/-) Remark/s
Auditory
Localization
Auditory
Tracking
d. Touch functions
Grading (+/-) Remark/s
Touch
Localization
Sharp and
Dull
e. Pain and other sensory functions
2. Visual Perceptual Skills
Grading (+/-) Remark/s
Body
Awareness/Scheme
Position in Space
Spatial Relations
Figure-Ground
Discrimination
Visual
Discrimination
Visual Sequential
Memory
Visual Memory
PERFORMANCE IN AREAS OF OCCUPATION
Dynamic Performance Analysis:
o write a short description of the activity, presentation of materials, etc.
o steps done by the client
o steps where the client had difficulty or where you provided assist
Client ability/ies
Occupational demands/supports
Environmental demands/supports
o interview part of the areas
o use tables
Example:
A. Activities of Daily Living (ADL):
1. Feeding: (independent / dependent / assisted (indicate level of assistance)
According to (informant) Upon observation Contexts
I. Play Participation
AI/AA - *Stage*
Play activities initiated by pt / given by therapist:
Indicate the activities given by the therapist and/or initiated by the child during the evaluation
RESPONSE TO PLAY ACTIVITIES / GENERAL BEHAVIOR:
( ) absent / unresponsive / inattentive
( ) hyperactive
( ) passive / shy
( ) crybaby
( ) irritable
( ) temper tantrums
( ) cooperative / playful
PLAY LEVEL According to PRATT:
( ) exploratory
( ) symbolic
( ) games
( ) constructive
Remarks:
PLAY LEVEL according to PIAGET:
( ) Sensorimotor
( ) Practice with Reflexes
( ) Coordination of Secondary Schemes
( ) Primary Circular Reaction
( ) Tertiary Circular Reaction
( ) Secondary Circular Reaction
( ) Beginning of Thought
( ) Preoperational
( ) Concrete Operational
( ) Formal Operations
Remarks:
According to (informant) Upon observation Contexts
II. Activities of Daily Living (ADL) – relevant areas
A. Bathing, Showering
According to (informant) Upon observation Contexts
B. Toilet, Toilet hygiene
According to (informant) Upon observation Contexts
C. Dressing
According to (informant) Upon observation Contexts
D. Swallowing/eating
According to (informant) Upon observation Contexts
E. Feeding
According to (informant) Upon observation Contexts
F. Functional Mobility
According to (informant) Upon observation Contexts
G. Personal device care
H. Sexual activity
III. Instrumental Activities of Daily Living (IADL)
A. Care of others (including selecting and supervising c/g)
According to (informant) Upon observation Contexts
B. Care of pets
According to (informant) Upon observation Contexts
C. Child rearing
D. Communication management
According to (informant) Upon observation Contexts
E. Driving and community mobility
F. Financial Management
According to (informant) Upon observation Contexts
G. Health management and maintenance
H. Home establishment and management
According to (informant) Upon observation Contexts
I. Meal preparation and clean up
According to (informant) Upon observation Contexts
J. Religious and spiritual activities and expression
K. Shopping
According to (informant) Upon observation Contexts
IV. Rest / Sleep
A. Rest
According to (informant) Upon observation Contexts
B. Sleep Preparation
According to (informant) Upon observation Contexts
C. Sleep Participation
According to (informant) Upon observation Contexts
V. Pre-formal / Formal Education Participation
According to (informant) Upon observation Contexts
VI. Social Participation
AI/AA - *Stage Parten*
EYE CONTACT:
( ) meaningful ( ) fleeting ( ) inconsistent ( ) absent
RESPONSE TO NAME CALLING:
( ) STRANGER ANXIETY:
( ) SEPARATION ANXIETY:
LEVEL OF SOCIAL INTERACTION ACCORDING TO PARTEN
( ) unoccupied ( ) solitary ( ) onlooker ( ) parallel ( ) associative ( ) cooperative
Remarks:
Meron po ba siyang mga kaibigan?
Meron po ba siyang mga nakakaaway? Kung meron, bakit?
According to (informant) Upon observation Contexts
Family
Peer, Friend
Community
VII. Standardized Assessment
CLINICAL IMPRESSION
OCCUPATIONAL THERAPY PROBLEM LIST
OCCUPATIONAL THERAPY GOALS AND PROGRAM
Occupation:
Area:
LTG1:
STG/s: Child will be able to
a.
b.
c.
Therapeutic Use of Self:
Therapeutic Use of Group:
Behavior Modification Techniques:
Environmental Modification Techniques:
Language Facilitation Techniques:
Sensory Integration Techniques:
Therapeutic Use of Activities:
a. Preparatory
b. Purposeful
c. Occupation-based
RECOMMENDATION
- Provide general caregiver and home recommendations that are not stated under your plan
- Specify skills or areas needed for further assessment
- Referral to other professionals / intervention (SP, PT, SPED, play group, etc.)
To the next OT:
To the parents:
Prepared by:
Beni Felucci V. Viray, OTRP
Occupational Therapist
License No. 0004641
